Rheumatoid Arthritis Flashcards

1
Q

What type of disease is RA

A

Autoimmune

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2
Q

Where does RA affect

A

Synovial joints
Hands feet knees hips

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3
Q

What are the 4 phases of pathophysiology for RA

A

INITIATOR PHASE- Injury, infection etc.
antigen presenting cells now seen as non-self
INFLAMMATORY PHASE- self antigens presented, clonal expansion of T and B cells
Insufficiently controlled by Treg Cells
SELF PERPETUATING PHASE- Inflammatory damage in synovium means self antigens are exposed causing immune response against cartilage and immune cells to gather.
DESTRUCTION PHASE- synovial fibroblasts and osteoclasts activated by cytokines (TNF, IL-6) causing destruction of bone and cartilage.

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4
Q

What do B-cells do in RA

A

Produce autoantibodies which bind to macrophages in synovium and sustain inflammation

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5
Q

What does rheumatoid Factor do

A

Directed against antigens usually present outside of joint

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6
Q

What might joint destruction be caused by?

A

CD4 T-cell cytokine causes RANK ligand promoting osteoclasts to resorb bone

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7
Q

How do you diagnose Rheumatoid arthritis?

A

Anti-CCP levels
squeeze test

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8
Q

What do T-cells do in Rheumatoid arthritis

A

Potentially activate monocytes, macrophages and synovial fibroblasts -> produces TNF-a, IL-1, IL-6-> induce production on matrix metalloproteases (MMP’s) which degrade cartilage

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9
Q

What are the signs and symptoms of RA?

A

Fever, weakness
Symmetrical inflammation
Progressive loss of function
Weight loss and fatigue

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10
Q

What are patients with RA and increased risk of?

A

CV risk
Infection
Respiratory disease
osteoporosis
Malignancy
depression

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11
Q

What is tested in blood tests for RA?

A

Usually anti-CCP (anti-cyclic citrullinated peptide)
Rheumatoid factor (RF)
C-reactive protein (CRP)
Erythrocyte sedimentation rate (ESR)

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12
Q

What tests are needed for a diagnosis?

A

Complete history taking-
Morning stiffness for more than 30mins
Stiff after resting
Family history and lifestyle
Clinical presentation-
Symmetrical effects of synovial joints
Symptoms worsen
Investigations-
Inflammatory markers
Haematological and immunological parameters
Radiological Investigations

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13
Q

What does NICE say for diagnosis of RA

A

Clinical examination shows synovitis
Determine RF and Anti-CCP antibodies (if -ve for RF)
X-ray hands and feet

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14
Q

What does DAS28 consider for RA? What is it?

A

Measure disease activity
1- No. of swollen joints (out of 28)
2- No. of tender joints
3- Measure ESR or CRP
4- Global assessment of health

more than 5.1 = active
less than 3.2 = low activity
less than 2.6 = remission!

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15
Q

What treatments are available for RA?

A

NSAID’s
Glucocorticoids
DMARD’s - methotrexate, sulfasalazine, leflunomide
Biologics - Anti-TNF
- IL-6 receptor inhibitor (tocilizumab)
- Anti B-cell (rituximab)
- Antibody blocking T-cell activation (Abatacept)
- Il-1 receptor inhibitor (anakinra)
Targeted tDMARD- JAK inhibitors: nibs
tofacitinib
baricitinib

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16
Q

Name some biologics which have anti-TNF activity

A

adalimumab
etanercept
infliximab

17
Q

What is the plan for newly diagnosed active RA

A

1st line: cMARD as MONOTHERAPY
(methotrexate, leflunomide, sulfasalizine)
Uptitrate
Bridge w/ glucocorticoid when changing DMARDS.
STEP UP- offer additional cMARD

18
Q

What should happen if medication for RA is maintained for a year without corticosteroids for flares?

A

step-down
Reduce drugs
If target then not met- return to previous regime

19
Q

How can patients control symptoms of RA?

A

NSAID’s - paracetamol ibuprofen etc.
Consider toxicities and risk factors
Offer PPI’s

20
Q

How can patients control a flare of RA?

A

Short term corticosteroid- prednisolone